I am as appalled by the media coverage of the Pulse Nightclub massacre and the Stanford Rape case as I am of the events themselves. I'm chairing a dissertation on rape and I have a clinical practice that is LGBTQIA friendly. The media turns these events into single incidents rather than common place occurrences. The rape case stands out only because of the articulate first person account of the victim. Rarely do we hear the words of the victims. And 7000+ words not only captured the nation but put focus on the judge for handing down the light sentence to Brock Turner. And there is a discussion about rape culture and the misrepresentation of men like Brock as boys and just drinking too much, and not as the face of the rapists they are. So that discussion is well needed. But the sentence itself is common. The rapist I saw a week or so ago was given 3 years for breaking a woman's jaw twice during her rape. He was out in less than two years. He's already violating his parole. I'll see 2 or 3 more just like him over the next few months. It's common. So women don't get to feel safe because we know. We know that reporting gets nothing more than a slap on the wrist. That going to court gets a laughably light sentence. That we will be blamed for the rape instead of the rapist. We know that. I was told my rapist couldn't be convicted so no charges were brought. He raped acquaintances. I know three other women he raped. There were no charges brought by the State.

The massacre at the Pulse Nightclub is marked by the lack of media coverage of it being a place of safety for people within the transgender drag Latinx community. It was a continuation of the violence that has been historical from the time of colonization on. It was the continuation of violence against the community that occurs within a daily basis. This is a community that wakes up knowing people want to kill them every day. It's not about guns or Muslims. It's about a massacre that normally happens piecemeal. The media usurps the community by not naming them. By not calling this what it was, part of the ongoing massacre of people of color, of the homosexual and transgender communities, of the marginalized.

My cisgender white male friends of privilege do not understand. They think nothing of walking outside, alone, at night. They think nothing of going to a nightclub and maybe having a drink. They do not understand why I own a gun, why I'm afraid, or what it means to be a survivor of crime. A survivor of rape. They think the police the police will help if something bad happens. They think the police will come. But what the media gets so wrong is that as members of these communities, we know the police will not come, if they do come they will come late and ineffectively, they will blame the community, and if we defend ourselves we will be vilified. The script the media endorses is that these are gun crimes or terrorist activites or the problems of mental illness. No. They are the problems of marginalization and dehumanization. There are countless murders and countless rapes. It's not about guns, or terrorists or the mentally ill. It's about a lack of safety and a lack of awareness of how often these crimes are occuring.

Depending on the study, somewhere between 58 and 79 percent of all psychological diagnoses have a substantial medical component. That's a very alarming statistic. In the 1970's the field of medical psychology was created to address this need. By the late 1980's it had all but dissappeared, replaced by the less medically intense health psychology field or the broader behavioral medicine field.

When I first went into practice I worked with a family practice physician. My office was located in his office. The referral question was simple: "This person has been seeing me (the MD) for 4 or more visits and the diagnosis is unclear" or "This person is not responding to treatment." Of the hundred or so people I saw over the first year, I diagnosed about 30 cases of cancer, 20 cases of heart disease, and 35 cases of endocrine disorders. The rest were a mixture of psychological conditions and non-compliance with complicated medical treatment. My private practice geared to work with heart disease and cancer was starting to be filled by men with what would eventually be diagnosed as HIV/AIDS. I drove to San Francisco on the weekends to be with a client who was being treated at San Francisco General. I stopped counting the deaths at 175 and closed my practice to start working for one of the insurance companies.

At a risk management seminar I was sitting at a table of physicians. They presented a case of a woman with persistent neck pain. The cardiologist at the table and I were arguing over the diagnosis. The case was presented in pieces, just like it is in a medical office. She had been cleaning the shower and her neck started hurting. It felt better after some rest but still didn't go away. She thought maybe she had the flu. I was telling the cardiologist the woman had a heart attack. He was telling me I wasn't a doctor. After the third visit for neck adjustment the woman collapsed at home. She'd had three heart attacks. I explained to the cardiologist that women experience heart attacks differently than men and they have different symptoms mainly neck and jaw pain, fatigue and muscle aches. Almost all my heart patients were women. Almost all were misdiagnosed in medical offices or even at emergency rooms.

The endocrine diagnoses were worse. Almost all my endocrine patients were misdiagnosed with depression, anxiety, or personality disorders. Some had endocrine tumors. Some of those tumors were malignant. Just trying to get the correct tests done or imaging studies done was challenging. Eventually I had physicians I worked with because we knew each other, and they understood what I did. For physicians not trained in clinical medicine, they decided I was psychic. For physicians trained in clinical medicine, they honed their skills and trusted them more than the lab studies they treated like oracles.

Now I tend to work with more neurological symptoms, recent head injury or abnormal test results that don't seem to correlate with any illness. When the Dr. House series was on television it was easier to explain what I did. That was a show about clinical medicine. I like the puzzle. I like figuring out what's going on.

If you don't have a diagnosis and have seen your physician for more than 4 visists, or if you aren't responding to treatment, contact me. I'm likely to be able to help with diagnosis and treatment.

Patient shaming. This time it happened to/about my cat. This happens by physicians (or vets) when they don’t know what is going on and all the treatment options they know of have been exhausted. It usually happens to people on the fourth visit either when there isn’t a diagnosis or the treatment is ineffective.

I ‘ve had Tatum since she was just under 2 years old. She was a hot mess. She was in several foster homes. The rescue organization referred to her as medically fragile. She had a couple of common cat conditions, namely cat acne, and bilateral herpes of the eyes. But she was ripping her face and ears open and the go-to diagnosis was some sort of unseen parasite. She was subjected to scrapings, dips, multiple medications and a food diet so extreme that she was only eating one brand of cat food and only turkey pate at that. She still had all the conditions. The rescue person dropped her off, did a cursory look at the house and ran out yelling “Start the car. They took the cat.”

I kept up with all the craziness for a year. Then I stopped the pills. I stopped the drops. I kept her eating out of ceramic or glass dishes. I started varying her food. No change. She ripped her face open and I took her to two vets. No parasites. It’s stress. Cat self-harm. Cat trauma. New people trigger it. Sometimes the other cat triggers it. Sometimes it’s a thunderstorm. She eventually gets over it. She’s been fine for the last several days.

She just turned five and I took her to the vet. New vet.
“She should be on L-Lysine twice a day” she said.

“I did that,” I said. “It does nothing.”

“She’s ripping her face open because of the cat acne. It’s painful” she said.

“No,” I said. “She rips her face open when she’s psychotic.”

“We can treat that. There’s medication for it” she said.

“I’ve given her creams and drops for a year. It does nothing. No thank you.”

“So you want your cat to be in pain. I guess you know everything.”

“She’s here for vaccinations. Can you do those?”

“Yes,” she said.

Stalemate.

It’s annoying. It happens because doctors are taught in medical school that they have to know everything. For many it hinders later collaborative practice. They blame patients with chronic medical conditions that don’t respond to typical treatment. They blame parents for children not improving. They blame people when they can’t diagnose. They refer to therapy as a last resort rather than as a first line of options. Switching doctors happens with disgruntled patients or being referred out to specialists is the common practice for physicians. It fragments treatment, limits history, and results in poorer medical care. As more physicians integrate psychologists into their practices hopefully this will lessen.

Disability is a complex system of insurance companies, state regulations, federal regulations and governmental bodies with competing and differing codes for determination. It’s confusing to a lot of people. Our office can help with all forms of evaluation.

DEFINITIONS

A disabling condition is a physical or emotional illness or collection of symptoms that impairs the ability to function in one or more areas of life.
Accommodations are methods to assist someone in performing tasks so they can function better.

Accommodations may include a device such as a computer that recognizes speech, or converts speech to text, or reads text aloud. It may be a wheelchair or a cane. It may be a device that helps to put on socks, or grab items, or button. It may be a device that helps someone hold a spoon, or fork, or pencil. It may be a cell phone or tape recorder. It may be a system of applications that says what color something is, what denomination of money someone has, or a prompting system to help with memory. It may be a medical device to test blood sugar, blood pressure, temperature, pulse. It may be extended time on exams, a private room, natural lighting, a test given on computer or a paper based test. It may be a service animal or emotional support animal. It may be voice activated door bells, light switches, smoke detectors. It’s not an advantage, but it may be an equalizer.

An off work notice. This is a letter to an employer indicating a disabled person is not able to function in their usual and customary job as a result of a temporary disabling condition. This usually needs to come from a physician (psychologists count as physicians in this regard). The person is expected to undergo some form of treatment to return them back to their usual and customary job.

Evaluation of disability by a treating provider. This is a letter or report of the symptoms and a description of functional impairments. This may be requested by an employer or by an insurance company handling a disability claim. This letter does not have to be written by a physician.

Evaluation of disability for the Social Security Administration. This is an evaluation of how an individual is able to function in their ability to perform simple work in the general labor market. The is not an evaluation of their ability to perform their usual and customary job. This is simple work. Examples would be the person who bags groceries at a grocery store and retrieves shopping carts, or the helper that waters plants at the local nursery. It involves some degree of judgment such as not putting the gallon of milk on top of the carton of eggs.

Evaluation of disability for accommodations. This is a complex evaluation involving multiple layers of documenting what is required and what is available. For conditions such as ADHD, or for tests such as licensing board tests these evaluations are lengthy and extensive.

We perform all tyes of evaluaitons on all age groups and write letters as part of those evaluations. Feel free to contact our office.

I explain complex trauma to my students by telling the story of my cat Tatum. I met Tatum through a cat rescue organization. Tatum was described as a fragile medically ill cat. I picked her up in my arms and she jumped out of my grasp. The rescue group had me sign several forms and gave me her medical history. Three foster homes in her six months of life. Countless medical visits. Found in a cardboard box in a McDonald's parking lot in Lancaster, California. She was prescribed multiple medications, creams, pills, a special diet, and she couldn't get along with other animals. She was "slow to warm up." "She's not to go outside. She gets terrified. She responds quickly to being sprayed in the face with water if she's doing something you don't want her to do."

The first time she ripped open her face I assumed what everyone had, that she had mites, or an infection, or some sort of parasite. The first vet didn't find anything but prescribed medication anyway. The second vet didn't prescribe because she was already on medication and nothing was changing. So I asked if it was possible it was just self-injurious behavior. "Oh, we call it delusional parasites" the vet said. So I did research.

Post Traumatic Stress Disorder occurs commonly in animals.

PTSD symptoms in pets can include:

Uncharacteristic aggressiveness

Fearfulness, trembling

Increased agitation

Decreased appetite and weight loss

Reduced interest in playing, going for walks, or interacting with other pets and/or people

Hypervigilance (an intense, “on guard” awareness of surroundings)

Tendency to be easily startled

Urinating or defecating inside (when previously housebroken)

Increased neediness or attachment

Unprovoked whining or crying

Excessive barking or meowing

Destructive behavior

Extreme escape behavior to avoid a stressor (such as chewing through drywall to attempt to flee during a thunderstorm)

Sudden changes in temperament

Hiding for no reason

Excessive panting

Pacing

Fear of being alone

Sleep disturbances

Avoidance of people, places, or things associated with a traumatic event

Once I decided Tatum was suffering from PTSD, I changed everything I was doing. The first thing I did was set up cardboard boxes all over the house. She investigated all of them. She would jump in a tall one and scratch frantically at the bottom. Eventually I realized she was digging to try to get to her lost litter mates. She made friends with a neighborhood cat that the neighbors could no longer keep and now lives with us. The older cat helped Tatum go outside, calm down when there was a noise, and learn to tollerate being around another animal.

I started taking her outside in the backyard. It took months to get her comfortable to go outside. Initially she could tolerate 30 seconds. Now she can stay out for an hour or more.

I stopped all the medication. It was doing nothing. I stopped the special diet. It was doing nothing. The face ripping lessened. If she gets stressed she rips her face or ears open and it heals in a day or so. She'll use the cardboard boxes if she's stressed, or hide on top of the kitchen cabinets. When not stressed she purrs, and cuddles. I have a predictable schedule. She has a predictable routine. Anything out of the ordinary and she starts ripping her ears or her face. Those events are infrequent now.

The students will ask what made her get crazy. And I explain that her world was a very scary place when she was a kitten. She was with her litter mates then suddenly put in a cardboard box in a noisy parking lot and separated from them and her mother. She was moved from one house to another. She had lots of painful and annoying medical treatments. Things changed constantly. She went to a noisy rescue with lots of other cats and was terrified. The only thing that seemed to stay the same was her food because she was put on a special diet. So the rescue thought that was what helped.

The same thing happens in people. They get in situations that are frightening, unpredictable and out of their control. They can't self-soothe. They revisit the trauma over and over trying to master it. We have good treatment for people with trauma. But trauma is exceptionally common in rescued pets. The story helps the students understand a bit better.

In 2006 I and a colleague stood up in an auditorium in San Jose at a California Psychological Association convention and spoke about what it was like to have a head injury, and how the research, done mainly by psychologists working for insurance companies and personal injury attorneys, was flat out wrong.

In 2006 basic information about concussion included the following INCORRECT information:

Concussion is a minor thing.

Everyone improves within a couple of weeks.

People who don’t get better either are faking or have preexisting problems.

Multiple concussions aren’t significant.

If you didn’t report loss of consciousness then you didn’t have a concussion.

Brains have a fixed amount of nerves and don’t increase or change nerves so rehabilitation isn’t needed.

Football players have multiple concussions and are fine and can continue to play after concussion.

Most people function like football players.

We’ve come a long way. Here’s what we know now:

Concussion is a traumatic brain injury with a change in brain function. It doesn’t require loss of consciousness.

Seizures can occur within 18 months of a traumatic brain injury.

Headaches decrease in intensity and severity within 5 years of a minor traumatic brain injury.

Informal cognitive rehabilitation is done by almost everyone following a brain injury and may help people get back some degree of functioning.

While many concussions are from sports related injuries, there are numerous people with concussion unrelated to sports.

Football players with multiple concussions can develop long-term cognitive impairment due to repetitive brain injury.

It’s 2016. Here’s what we need to know:

In what ways do women and children with brain injuries from concussion differ from men or professional athletes with concussion.

We have statistics on emergency room visits for people with concussion. How many people never go to the emergency room following concussion? Is this similar or different from the population of people that do go to the emergency room?

What types of cognitive rehabilitation produce the most benefit for various types of injuries?

Our office evaluates people to provide information on neuropsychological functioning. If you need an evaluation feel free to contact us at 818-389-8384.

The new information on the Zika virus is that there is a confirmed case of sexual transmission of the virus in Texas. This means that anyone, male or female, traveling to an area where the virus is epidemic, or anyone who has flu like symptoms following being bitten by a mosquito should:

Not donate blood.

Not engage in sexual activity without using a condom.

Be closely monitored if you or your partner become pregnant following symptom development. An ultrasound at 20 weeks to check head size for microcephaly may be indicated.

It would be appropriate to ask the CDC to do something to protect the blood supply.

It would also be important to identify anyone that has tested positive for the Zika virus and develop a data base to evaluate long term sequela. Zika is a virus that can be expected to produce long term complications following infection. For many people this may simply be arthritis and may be quite mild. However, given the affinity of this virus for nerve cells in fetuses causing microcephaly, it would not be a stretch to expect that it may produce complications in nerve cells in adults.

Possible complications:

Arthritis. This has already been found in people with the virus.

Neuropathy, that sensation of pins and needles people experience when their arm or leg falls asleep.

Multiple sclerosis like symptoms from changes in nerve cells.

Guillain-Barre syndrome, an ascending slow paralysis or weakness already associated with the virus.

Muscle pain and weakness, already associated with the virus.

Since the virus and vector are similar to Dengue fever, hemorrhage, thrombocytopenia, or other blood disorders may also be complications.

For most people the Zika virus is a mild case of flu like symptoms if they notice anything at all. For others, like pregnant women it can result in their children having abnormally small heads and brains, known as microcephally. For others it may produce joint pain, or progressive symptoms of paralysis known as guillain barre syndrome. Fever, rash and runny eyes are common.

Zika virus is a viral infection of the blood carried by mosquitos. Aedes aegypti, the mosquito that carries the virus, lives in tropical and subtropical areas throughout the world. The mosquito strain is in the United States but their aren't enough infected people living in the United States to serve as hosts. It originated in Uganda Africa and was found in a rhesus monkey in 1947. In 2013 it caused significant human outbreaks in French Polynesia. It is likely also able to be sexually transmitted. I say likely because blood borne viruses are usually also sexually transmitted and the virus has been isolated in semen. The disease is most prevalent in South America, but it's also present in other countries. If it's not already in the United States, it will likely be here soon. There is no cure. Prevention measures are to avoid pregnancy in countries where the infection is in epidemic proportions and to avoid mosquitos. Treatment with antiviral medications have limited impact. Several pharmaceutical companies are working on a treatment or preventative medication.

In the meantime, if you can avoid traveling to tropical areas, especially if you are pregnant, then do that. Preventative treatment will likely be available within the next 2 to 5 years.

If you ever have any questions about illness, disability or clinical trials, feel free to contact me. 818-389-8384.

Headaches are a common phenomena. It's one of the most common problem I treat in clinical practice with exceptionally good outcomes. The first step in treatment involves identifying the type of headache somone has.

There are multiple types of headaches.

Muscle tension headaches-These headaches are caused by muscle strain and general muscle tension. If they occur on an occasional basis they can be relieved by stretching, massage, accupuncture/accupressure, changing position/ergonomics, or simple over the counter pain medications like aspirin, Tylenol, or Aleve.

Medication over use headaches--also known as rebound headaches. If someone is taking over the counter pain medications like aspirin, Tylenol or Aleve more than twice a week, or a triptan (migraine medications like Zomig or Imitrex) more than 10 days a month, then they are likely to need assistance in detoxing from these medications.

Dental pain headaches--bruxism (the grinding of teeth) or temporomandibilar joint pain (TMJ) can cause headache. A visit to the dentist can help with a fitting for a bite guard to lessen the stress on the teeth jaw and the joint of the jaw. Popping or clicking of the jaw helps with diagnosis.

Cluster headaches--these are allergy related headaches. They usually occur on one side of the head, the affected eye on that side gets red, the pain is excruciating, the nose may run. They typically occur at the same time of day and the same time of year. Oxygen helps relieve pain as does antiallergy medication like a histamine blocker, or a triptan. Alcohol, cigarettes, high altitude, and pollen levels can be triggers.

Migraines--migraine headaches are vascular headaches in which the hands and feet get cold and the blood vessels constrict. There may be a distinctive aura or prodrome of flashing lights, visual patterns, or neurological symptoms, that occur with the headache. There are YouTube videos of people with complex migraine and neurological symptoms that start to resemble symptoms of stroke with loss of speech. Migraines often have identified triggers and can be treated with triptans to lessen the intensity or severity of the headache. Keeping a log and knowing the triggers can help.

Caffeine withdrawal headaches--caffeine is a stimulant that people can be dependent upon. When attempting to cut back on heavy caffeine substitute half decaffeinated with half caffeinated products and decrease the amount by one drink per day until you reach a reasonable level. If you are drinking more than 10 cups of coffee or are treating excess fatigue with high doses of caffeine, you need to be seen by a physician to evaluate the reason for the fatigue.

Orgasm headaches are pain that follows having an orgasm. These headaches need to be evaluated by a physician with an MRI due to a rare neurological problem involving the arteries in the brain not functioning properly. Simple orgasm headaches with no neurological symptoms may be prevented by taking medication prior to having sex.

Sinus headaches are caused by sinus pressure and sinus pain. There may be an underlying sinus infection. Dental infections can spread to the sinuses as well. Often these are mistaken for migraines, but the hands and feet don't get cold, and there may be a nasal discharge.

Ice cream headache-also known as brain freeze headaches occur when eating something cold like ice cream. These headaches go away when the roof of the mouth warms back up.

Chronic daily headaches-these are often medication overuse headaches. They occur more than 15 days a month for at least three months. In cases where triggers and detoxing off meddications is not effective Botox injections have been helpful.

Hormonal headaches--these can occur with changes in hormone levels due to menstruation or pregnancy. They occur during the first few months of pregnancy or for a few days before or after a menstral cycle. Changes in food to include B vitamins and magnesium may be helpful. Evaluation of hormone levels may help reduce or eliminate these headaches.

Post-concussive headaches--these headaches are of migraine like severity and occur for a period of around five years following a head injury. They frequently are accompanied by slight neurological symptoms and rarely respond to medications. They lessen in intensity and severity over the course of five years. Headaches following concussion that are increasing in severity over that time frame need to be evaluated by a physician with neuroimaging.

Headaches with hypertension--severely high blood pressure can cause headaches.

Severe headache with neck pain/stiffness and fever requires a trip to an emergency room.

Headache with nausea, vomiting, and difficulty with speaking or walking requires a trip to an emergency room.

Headaches described as the worst pain ever-requires a trip to the emergency room.

We can help you evaluate and manage headaches. Feel free to contact us. 818-389-8384.

Autoimmune disorders and viral infections are strongly linked together. There are more than 80 identified autoimmune diseases. Viruses, bacteria and other types of infections are recognized as major environmental triggers for the body starting to attack itself.

Chronic cytomegalovirus (CMV) one of a type of herpes virus that causes mild flu-like symptoms has been linked to the development of Sjogren’s syndrome. Sjogren’s syndrome is the second most common autoimmune disease in humans impacting more than 4 million people in the United States. Sjogren's syndrome causes dry eyes, a dry mouth, and can cause joint pain, increased dental decay, swollen salivary glands, vaginal dryness, persistent cough and fatigue.

The research showing some of the mechanisms for the linkage may help with future treatments.